Leeds Teaching Hospitals NHS Trust

3. Ms P complains about her care by the Trust. She says it missed opportunities during antenatal ultrasound scans to identify her son, B, had a heart condition.

4. Ms P says if her son’s heart condition had been picked up earlier there would have been the opportunity to plan treatment for him that may have saved his life. She has been devastated by the loss of her son and feels her life ended when he died.

5. Ms P wants the Trust to accept what went wrong and its assurance it will act to make sure this does not happen again.

6. Ms P became pregnant in 2017. She went to antenatal appointments at the Trust's maternity unit. She had ultrasound scans (which use high-frequency sound waves to assess organs and structures in the body) throughout her pregnancy and these did not identify any concerns with her baby.

7. B was born in early July 2018 by caesarean section. There were no documented concerns about his health and Ms P was discharged the next day.

8. In September 2018 Ms P took her son to their GP for his first set of immunisations. Ms P took B home and gave him Calpol (paracetamol for children to treat pain and higher temperature) as instructed. She noted he was not feeding much that evening, felt hot and seemed weak.

9. Later that night B became very unwell and stopped breathing. He was taken to hospital where doctors tried to resuscitate him without success and B sadly died.

10. A post-mortem revealed B died from an undiagnosed and rare heart condition, cardiomyopathy of non-compaction phenotype.

11. We extend our sincere condolences for Ms P’s loss. We understand she wants to know if different care could have prevented her son’s death.

Antenatal scans

15. Before we decide to conduct a detailed investigation into a complaint, we look for signs something has gone wrong. We do this by comparing what should have happened with what did happen. We have carefully considered the available evidence and the relevant standards to reach our decision for this complaint.

16. Ms P complains the Trust missed opportunities to identify her son had a heart condition, particularly during the 20-week scan that looks for fetal anomalies. She questions if her son’s heart condition could have been identified on this scan and if anything was missed.

17. The Trust has said the antenatal scans did not reveal any concerns and her son’s heart was checked appropriately at 20 weeks.

18. Ms P had ultrasound scans on 9 August 2017, 1 September 2017 and 27 December 2017. Our adviser has explained these scans were done in the early stages of pregnancy. It was too soon to check for cardiac abnormalities because the baby’s heart and its major blood vessels had yet to form.

19. On 13 February 2018 Ms P had a 20-week anomaly scan. The NHS fetal anomaly screening programme (FASP) recommends women have this scan at 20 weeks. It looks for 11 different conditions in the developing baby, including defects in the abdominal wall, cleft lip and serious cardiac abnormalities.

20. The NHS ‘Fetal Anomaly Screening Programme Handbook’ sets out the minimum checks sonographers (who carry out ultrasounds) should do of the fetal heart. The sonographer should look at the four chambers and the vessels and make sure everything is connected as it should be.

21. Our adviser said cardiomyopathy affects the heart muscle. If the sonographer sees the fetal heart is enlarged compared with the size of the chest cavity, this may be an indication of the condition. Cardiomyopathy can develop during pregnancy or after the baby’s birth.

22. The scan report from 13 February says several of the anatomy checks were completed, but noted ‘rescan required at the next available appointment for lips and heart’.

23. The FASP handbook says if the image quality of the scan has been compromised and the heart could not be clearly seen, the woman should be offered a ‘single repeat scan’ by 23 weeks’ gestation to complete this check.

24. Our adviser said it was appropriate to ask Ms P to return for a rescan to make sure the sonographer could complete the checks of the lips and heart. This can be necessary because of the baby’s position.

25. Ms P went for another scan on 22 February, when she was at 21 weeks and six days gestation. The scan report says the baby’s heart and face were ‘seen’ and ‘the anatomy scan is now complete, no abnormality detected’.

26. Our adviser reviewed these scan images and noted no images of the heart had been saved.

27. The FASP handbook explains the information and images NHS organisations should record and save from the 20-week scan. For the heart, it says ‘measurement not required’. For each part of the heart’s anatomy checked it says ‘images/measurements to capture/archive: No’.

28. While the Trust did not save images of B’s heart, we are not critical of this because the FASP handbook says clinicians do not have to do this.

29. The scan report from 22 February states the sonographer looked at the heart and determined the scan showed no abnormalities. Our adviser told us the sonographer completed the checklist in line with FASP guidance.

30. Our adviser further explained there are no more specific checks of the fetal heart after the 20-week scan unless there is a particular reason to do so. In this case, clinicians did not identify any potential concerns with B’s heart during Ms P’s pregnancy.

31. Following careful consideration of the records, the advice we have received and the relevant guidance, we have not seen signs anything went wrong in the scans carried out by the Trust. We consider the Trust acted in line with the NHS FASP guidance when completing Ms P’s antenatal scans.

32. We understand why Ms P has questioned if clinicians missed anything and if more could have been done to prevent the very sad loss of her son. We hope we have been able to explain why we do not have concerns with the Trust’s actions and why we will not be taking this complaint any further.

1. The Parliamentary and Health Service Ombudsman has carefully considered Ms P’s complaint about the Leeds Teaching Hospitals NHS Trust (the Trust). We have not seen signs anything went wrong in the antenatal scans the Trust did during Ms P’s pregnancy.

2. We have set out how we reached our decision. We hope this will give Ms P some answers and clearly explain why we will not be taking her complaint any further. We thank her for bringing her complaint to us and acknowledge how important this is to her.